Commercial Insurance Questionnaire
Customer Details
Entity Name
*
Contact Name
*
First Name
Last Name
FEIN
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your physical address the same as your mailing address?
*
Please Select
Yes
No
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Description of Operations
*
Do you manufacture products?
*
Please Select
Yes
No
Please describe the products you manufacture and their use.
*
Annual Revenue
*
Annual Payroll
*
Number of Full-Time Employees
*
Number of Part-Time Employees
*
Coverages Requested
*
Property
Auto
General Liability
Worker's Compensation
Umbrella Liability
Other
Do you use subcontractors?
*
Yes
No
Maybe
If so, please provide the Annual Subcontractor Cost
*
Please describe the Services Provided by Subcontractors
*
Upload Current Policies
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of
Upload Current Loss Runs
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Please provide any other information you deem pertinent to your commercial insurance, including any coverage concerns and/or requests.
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